Provider Demographics
NPI:1043561285
Name:MARK, KELLY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 121ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-2827
Mailing Address - Country:US
Mailing Address - Phone:062-853-2409
Mailing Address - Fax:
Practice Address - Street 1:330 112TH AVE NE STE 302
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:206-853-2409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WAPY60781335103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health